Sexually Transmitted Infections (STIs) - Infectious Dis.

Overview
STD's are one of the most common gynecologic ER presentations All sexually active partners should be screened for STDs Risk factors incude multiple sexual partners unprotected sexual intercourse young age at first intercourse men who have sex with men Common presentations are ulcerations of the vulvovaginal region abnormal vaginal discharge inguinal rashes inguinal lyphadenopathy abdominal pain 25-50% have multiple genital tract infections

Disease	Introduction	Presentation	Evaluation	Treatment
Primary syphilis	Caused by Treponema pallidum (spirochetes)	Appears in 2-10 weeks Painless genital ulceration (chancre)	Dark field microscopy, VDRL/RPR (a rapid but nonspecific screening test), and/or a FTA-ABS (specific and diagnostic, the gold standard)	Penicillin
Secondary syphilis		Appears 1-3 months after primary infection Maculopapular rash on palms and soles, fever, headache, and generalized lyphadenopathy Condylomata lata (moist lesions on the genitals which are highly infectious)	-
Tertiary syphilis		Aortic aneurysm and aortic regurgitation Granulomatous gummas of the CNS, heart and great vessels	-
Gonorrhea	Caused by Neisseriae gonorrhoeae	Dysuria, urinary frequency, and purulent yellow-green discharge May progress to PID, high rate of coinfection with with chlamydia Can cause proctitis in the setting of anal intercourse	Evaluation should include cervical and urethral cultures for chlamydia and gonorrhea Clean catch urine culture to rule out UTI Saline/KOH/Gram stain of vaginal discharge	Ceftriaxone, also treat for presumed chlamydia infection If urethritis is refractory to azithromycin, consider Trichomonas and treat with metronidazole
Chlamydia	Caused by Chlamydia trachomatis serotypes D-K	Often asymptomatic, but may cause dysuria, cervicitis, PID, lymphogranuloma venereum, or infertility	Chlamydia antigen test	Tetracycline/doxycycline, azithromycin for cervicitis Use erythromycin base or amoxicillin in pregnancy Do not need to routinely treat for presumed gonorrhea innection, but should in patients with confirmed gonorrhea or high risk patients
Venereal warts (condylomata acuminata)	External lesions associated with HPV 6,11, endocervical warts caused by HPV 16, 18, 31, 33. Transmitted sexually and have a incubation period of 1 to 6 months	Painless, soft, fleshy, "cauliflower like lesion" Lesion can be on the vulva, vaginal wall, the cervix, and the perineum	Biopsy lesion with 5% acetic acid to detect condylomata acuminata	No treatment is satisfactory. Relapse is frequent and requires retreatment Treatment modalities include podofilox (an antimiotic), cryotherapy, laser surgery, or electrocauterizations, and biopsy, imiquimod (interferon inducer) are widely used but require multiple applications and frequently fail Presence during pregnancy does not require cesarian section
Herpes	Caused by HSV-2	Parasthesias and burning followed by painful vesicles and ulcerations In primary infections patients may present with fever, malaise, and adenopathy	A Tzanck smear for lesions suspicious of HSV	Topical acyclovir ointment during flare-up, oral acyclovir to decrease rate and severity of recurrence